Analysis Barge Stability Given the absence of accurate information on the lightship condition, possible water ingress in the watertight compartments, and the difficulty in determining the height of the cargo's centre of gravity, the TSB performed post-occurrence calculations to establish best- and worst-case stability scenarios.17 The results, when compared against STAB8 and International Maritime Organization (IMO)18 standards, are presented in Table1. Table 1. Transverse stability calculations from arrival at Sheet Harbour until capsizing At the time the barge left Sheet Harbour on 26 October 2006, its stability was very limited. Before the weather was taken into consideration, the barge did not comply with the minimum (albeit non-mandatory) STAB8 and IMO stability criteria. The weather then had the following effects: The cargo absorbed the rain and spray. This was probably intensified by the reduced freeboard and the list at departure from Sheet Harbour. This added an estimated 90tonnes. It also would have increased the draught another 0.05m, reduced the freeboard by the same amount, and slightly increased theKG. The steady wind caused the barge to heel another 0.5, further reducing freeboard and submerging the port quarter of the deck shortly before capsizing. Wind-driven waves flooded the deck, increasing water absorption. When the steady wind is taken into account (see Table1, condition6), stability decreases further, even with an optimistic KG. In a worst-case scenario, the righting arm is less than the heeling arm, causing the loss of all positive stability. Gusting winds and increased wave action further contributed to the complete loss of positive stability. It is likely that the barge capsized when the wind was gusting at its strongest. In short, the barge capsized when the range of stability, which was already low at departure from Sheet Harbour, was reduced in deteriorating weather conditions. Stability Booklet Good seamanship includes verifying a vessel's stability to determine, inter alia, how it will react to various external forces. When the barge left Sheet Harbour, it did not have a stability booklet, nor was one required. Moreover, no stability calculation had been done by the crew- before or after loading- and the master did not have any loading instructions from the company. The crew loaded the OTM3072 based on past experience, even though doubts about the vessel's stability had earlier been expressed and the company had received a TSB safety communication to that effect. Consequently, when the barge left Sheet Harbour, the master did not have the necessary information to assess the barge's transverse stability. Modifications to the Barge Before a vessel is built or modified, the designer and owner determine the type of vessel desired, the main routes and ports that will be served, and the type of services to be provided. Once these have been established, the designer determines the main characteristics of the vessel, including the stability.20 Data submitted to the naval architect in 2005were never verified; the resulting stability assessment was therefore not representative of the anticipated operations. Moreover, although the barge's lightship displacement was verified in the fall of2005, this was done without an internal inspection of the compartments. Then, following modifications, the barge did not undergo an inclining experiment to determine the new lightship characteristics. When the barge started operations again on 20October2005, the master and the managing owner were not aware of the fact that the range of stability was limited for the type of service to be provided. Therefore, despite preliminary calculations showing limited stability, no comprehensive study of its stability characteristics was done before the barge was modified. Safety Management System Sound safety management practices are essential to identify and reduce/eliminate the risks and dangers associated with a vessel's operation. These include a safety policy, appropriate procedures to safeguard the operation of the vessel, and training of personnel. Before the occurrence, the company's safety management policies, procedures, and practices were limited and, as a consequence, the company was unable to identify and reduce stability-related risks. The load lines assigned to the barge before it was put in service in the UnitedStates were not mandatory in Canada and were not used as operational limits essential to stability and safety. The amount of cargo loaded was increased on a trial-and-error basis, as opposed to a more systematic approach based on specific stability data. The high GM values, obtained in summary calculations, were interpreted as an indication of good stability, when they were merely an indication of stability in an upright condition, in contrast to stability at large angles of heel. The naval architect's recommendations regarding the operational limitations to maintain the barge's stability and buoyancy were ignored, particularly regarding the ballast, list, trim, and freeboard. There was no follow-up on the concerns of the crew of the OceanFoxtrot regarding the accuracy of the data given to the naval architect in October 2005, and shore-based personnel took no corrective action. Shore-based personnel performed no control or monitoring to ensure the implementation of the naval architect's recommendations, and allowed the installation of a ballast system for compartments that were supposed to remain dry. The barge was modified without a detailed analysis of the impact on its stability. After the modification, no inclining experiment was done, which would have made it possible to establish the barge's lightship displacement and itsKG. Although the TSB issued an MSI letter regarding the barge's stability, no corrective action was taken. The organizational structure of the parent company encompasses several independently managed companies. Although not required, the parent company was in the process of implementing the ISMCode for some of its subsidiaries. However, the managing owner was not part of this process. Policies, procedures, and practices implemented through a safety management system increase the chances that stability-associated risks are identified, reduced, or eliminated. In the absence of a systematic and integrated safety management system, it is likely that managing owners will not be able to identify all operational risks and take the appropriate corrective action. Regulatory Framework Carriage of cargo by barges represents a significant part of Canada's transportation industry, and there have been numerous occurrences involving this type of transport. However, with the exception of barges carrying oil in bulk, the operation of barges falls largely outside of the current regulatory framework. Regulatory oversight, such as initial/regular inspection regime, could have made it possible to identify deficiencies such as: the height of the barge's uprights being increased twice without a complete stability analysis; ballast water being regularly added in the ballast tanks without a complete stability analysis; the damaged skeg not being repaired in a timely manner; the barge being regularly loaded such that the load line was submerged. Although such a regime does not exist in Canada, UnitedStates regulations require that barges be inspected, meet minimum stability standards, show load lines, and hold a load line certificate. TC has initiated a study of the tug and barge industry and has tasked a working group to examine this issue.21 However, as long as this work is incomplete and a suitable regulatory framework has not been adopted- one that provides an equivalent level of safety as that afforded to conventional vessels- some managing owners may continue to operate barges beyond their structural and stability limits, thereby compromising the safety of this type of vessel. The barge capsized when the range of stability, which was already low at departure from Sheet Harbour, was reduced in deteriorating weather. The master did not have the necessary information to assess the barge's transverse stability. Despite preliminary calculations showing limited stability, no comprehensive study of its stability characteristics was done before the barge was modified.Findings as to Causes and Contributing Factors The barge capsized when the range of stability, which was already low at departure from Sheet Harbour, was reduced in deteriorating weather. The master did not have the necessary information to assess the barge's transverse stability. Despite preliminary calculations showing limited stability, no comprehensive study of its stability characteristics was done before the barge was modified. In the absence of a systematic and integrated safety management system, it is likely that managing owners will not be able to identify all operational risks and take the appropriate corrective action. As long as a suitable regulatory framework has not been adopted, some managing owners may continue to operate barges beyond their structural and stability limits.Findings as to Risk In the absence of a systematic and integrated safety management system, it is likely that managing owners will not be able to identify all operational risks and take the appropriate corrective action. As long as a suitable regulatory framework has not been adopted, some managing owners may continue to operate barges beyond their structural and stability limits. Safety Action Action Taken Transport Canada On 10 January 2006, the TSB sent Marine Safety Information letter01/06 (Dangerous Navigation in Confined Waters on the St.Lawrence River with an Unsteady Cargo of Wood Chips on Board the Barge OTM3072) to Groupe Ocan, Inc. (the parent company), and copied Transport Canada (TC) and other stakeholders. In response to this letter, TC included the following information, which was further addressed at the Canadian Marine Advisory Council (CMAC) conference in November2007: definition of an integrated tug and barge combination; standards versus regulations for tug and barge combinations; inspection of barges whether or not they are carrying oil; assessment of bollard pull; and certification of barge masters and mates. In addition, a special working group was tasked to initiate discussions based on the aforementioned points and to propose recommendations at the next CMAC conference, in May2008. This working group comprises members from the industry, central labour bodies, the St.Lawrence Seaway, and TC. As of July2008, no significant progress had been made, and these issues still await resolution. With the entry into force of the Canada Shipping Act, 2001, new safety requirements have been introduced. Under Subsection106(1) of the Act, authorized representatives must ensure that the vessel and its machinery and equipment meet the regulatory requirements. They must also develop procedures for the safe operation of their vessels, for dealing with emergencies, and for ensuring that the crew and passengers receive safety training. Additionally, Section206 of the Marine Personnel Regulations requires that crew members receive on-the-job training and be familiarized with their operational roles and responsibilities. To assist operators to comply with these new requirements, TC is in the process of developing a safety management system that is tailored to the specific needs of the Canadian domestic fleet and that will be known as a domestic safety management system. The guidelines for this system are currently under development and are being drafted in collaboration and consultation with TCregional service centres and industry. A draft domestic safety management system will be tested during a pilot project with the Council of Marine Carriers, an industry association in British Columbia, in which five towboat companies have volunteered to participate. The pilot project is anticipated to start in early2009, and will run for a period of two years. With the development of a domestic safety management system, TC will support the Canadian domestic fleet to strengthen its safety culture and meet the full intent of the Canada Shipping Act, 2001. A domestic safety management manual that is currently under development will eventually be made available to all operators, and will become an option they may pursue in order to comply with these new regulatory requirements. Division 2, Subsection08(3) of the new Cargo, Fumigation and Tackle Regulations, which came into force on 01July2007, states that the master of a vessel- where a barge is considered a vessel-is required to have comprehensive stability information on the effects of loading, carrying and unloading solid bulk cargo, or must comply with Regulation7.2.1 of ChapterVI of the International Convention for the Safety of Life at Sea, 1974(SOLAS), which requires a vessel to have a booklet that includes among other things, stability data. Parent Company Since the occurrence, the parent company has obtained its document of compliance under the International Safety Management Code (ISMCode). Many tugs belonging to the parent company's different subsidiaries now have a safety management certificate. However, the managing owner of the tugs OceanFoxtrot and OceanEchoII does not have a document of compliance and these vessels do not have a safety management certificate.